Washington D.C., USA, July 2012www.aids2012.org Estimating the Costs and Impacts of HIV/AIDS Programs for Botswana Examples of the ART Program and Various Prevention Strategies Presented by:Peter M. Stegman, Sr. Economist & Managing Director, Futures Institute Southern Africa Office ACHAP Symposium - International AIDS Conference Washington DC, USA 23 rd July 2012

Washington D.C., USA, July 2012www.aids2012.org Botswana Background Despite its successes, Botswana still suffers one of the worst epidemics globally The national ART program has greatly curbed HIV-related mortality by achieving 90% coverage Prevention efforts, however, have not kept pace – accounting for less than 10% of total AIDS expenditure 1 1 National AIDS Coordinating Agency (2011), National Operational Plan for HIV and AIDS, GOB.

Washington D.C., USA, July 2012www.aids2012.org Some Limitations of study Study done in advance of release of important up-to-date data Completeness and currency of program data was sometimes a challenge Lack of data on CD4 progression rates and ART mortality by CD4 count at initiation

Washington D.C., USA, July 2012www.aids2012.org Spending for HIV and AIDS 2 Since the ‘90s the GoB has increased health spending By 2008 GoB was spending BWP 1.5bn ($ 220m) on HIV/AIDS annually Over the same period, donor funding also increased Currently GoB funds about 70% of national HIV/AIDS program Faced with scaled back donor funding, the global economic crisis and constrained domestic revenues, GoB is concerned about HIV/AIDS program sustainability 2 National AIDS Coordinating Agency (2010), Botswana National AIDS Spending Assessment , GOB.

Washington D.C., USA, July 2012www.aids2012.org The ART Program in Perspective Program started in 2002 in four primary sites By 2004 there was at least one treatment site in each of the 27 health districts Presently there are 32 ART sites and 212 satellite dispensing clinics across the country At end of March 2012 there were just over 184,000 people on treatment In 2010, the WHO recommended easing ART initiation guidelines to levels <CD4 350

Washington D.C., USA, July 2012www.aids2012.org Modeling ART Guideline Change Created baseline projection in which ART initiation threshold was CD4 250 Developed alternative scenario in which ART initiation threshold was relaxed to CD4 350 In both scenarios coverage was held at 90% The difference between the baseline and the CD4 350 scenario produced counterfactual impacts and costs for the ART program to 2016

Washington D.C., USA, July 2012www.aids2012.org Estimated New & Existing ART Patients

Washington D.C., USA, July 2012www.aids2012.org Additional Eligible ART Patients Due to Guideline Change to CD4 350

Washington D.C., USA, July 2012www.aids2012.org Increased Care & Treatment Costs Amounts for OI are marginal in either case and are therefore not visible here

Washington D.C., USA, July 2012www.aids2012.org Prevention Scenarios Baseline CD4 350 High Impact Prevention Universal Access

Washington D.C., USA, July 2012www.aids2012.org Number of New Infections by Scenario

Washington D.C., USA, July 2012www.aids2012.org Costs by Intervention & Scenario

Washington D.C., USA, July 2012www.aids2012.org Incremental Costs of Prevention Scenarios IndicatorBaselineCD4 350High Impact Prevention Universal Access New Infections ( ) 63,70051,00038,20032,400 Infections Averted 12,70025,60031,300 Total Cost in Millions of US$ ( ) $2,170$2,430$2,530$2,750 Additional Cost in Millions of US$ $255$360$575 Cost-effectiveness per infection averted (excludes deaths averted) $20,200$14,000$18,300 Incremental Cost- Effectiveness Ratio $20,200$7,900$37,300

Washington D.C., USA, July 2012www.aids2012.org Incremental Costs of Prevention Scenarios IndicatorBaselineHigh Impact Prevention CD4 250 High Impact Prevention CD4 350 New Infections ( )63,70047,60038,200 Infections Averted 16,20025,600 Total Cost in Millions of US$ ( ) $2,170$2,270$2,530 Additional Cost in Millions of US$ $100$360 Cost-effectiveness per infection averted (excludes deaths averted) $6,500$14,000 Incremental Cost-Effectiveness Ratio $6,500$7,900

Washington D.C., USA, July 2012www.aids2012.org Total Costs by Scenario

Washington D.C., USA, July 2012www.aids2012.org Conclusions Future benefits of raising ART initiation threshold to <CD4 350 for general population include infections averted and reduced HIV-related mortality Depending on the rate of increase in new ART patients, the MOH may be able to cope through “spike” period High impact prevention strategy is cost effective and averts infections, but without expansion of ART, the cost in avoidable HIV-related deaths may be much too high

Washington D.C., USA, July 2012www.aids2012.org This report was a collaborative effort between: The conclusions and recommendations of this report are to provide the MOH and the Government of Botswana with the evidence to make appropriate, informed decisions about the pace and scope of treatment and prevention program scale-up. Ntwa e Bolotse

Washington D.C., USA, July 2012www.aids2012.org Thank You